As UK legislation comes into force today, requiring tobacco products to be sold in plain, standardized packaging, public health doctor David Roberts looks at Cochrane evidence on mobile phone-based interventions to help people quit smoking.

How many people are smokers?

Globally, some 20% of people over the age of ten were smokers in 2012. In some countries smoking remains common, in Russia 32% were smokers in 2012, and the figure was as high as 38% in Papua New Guinea and other Western Pacific states; the figure for the UK was 20%. When you look at men the figures are higher, 22% in the UK, and as high as 52% in Russia. These percentages translate into a big population burden: even in relatively low prevalence countries like the UK, there were 5.4 million smokers in 20121.

Why should people quit smoking?

Smoking tobacco comes second only to poor diet in causing ill health in England, and accounts for just over 10% of the total amount of deaths and disease in the country2; worldwide, tobacco is the biggest cause of preventable ill health and early death3. Quitting smoking significantly reduces the risk of its related serious diseases such as cancer and heart disease3.

Why do they need help?

The majority of smokers want to quit, and around half will have tried to quit in the last year3. Unfortunately, due largely to the cravings caused by withdrawal from the nicotine in tobacco, quitting is hard; without help, only around 6% of quitters will still be non-smokers a year later3. Many would-be ex-smokers do not seek help when they quit, but the chances of successfully quitting are much improved when smokers receive professional support4. This support comes in the form of behavioural support such as education, motivation and advice on how to quit successfully; or pharmacological (medication-based) support, whether by using nicotine replacement therapy (NRT), such as nicotine gums, or anti-depressants and other drugs that reduce the cravings. A recent Cochrane review showed that behavioural and pharmacological support work best in combination, increasing the chances of quitting at 6 months by 83%4. However, many smokers only use pharmacological support (if any), particularly NRT that is more easily obtained over the counter at pharmacies, when attempting to quit.

People wanting to quit smoking can seek help via their mobile phones without needing to see a health professional

Why use mobile phones?

So, how do we connect would-be quitters with professional behavioural support? As a public health doctor, I have spent too many fruitless hours trying to approach the public in shopping centres, hospitals and supermarkets to ask them about their health, often to only attract the attention of the ‘worried well’ who would benefit least from advice. Such ‘outreach’ activities can be more effective when well-targeted, but this is time consuming and difficult. Doctors and nurses in primary care can also give advice, but they have limited time to offer continuing support, and many younger smokers will rarely visit primary care.

Instead, mobile phones are increasingly being used for this purpose: smoking cessation services internationally are using mobile-delivered support, which can be initiated by the smoker without the need to see a professional face to face. The UK National Health Service offers text messages and apps (applications that run on smartphones), and many US quit-lines offer text message based support in addition to phone counselling.

As use of mobiles and mobile broadband continues to grow, and outnumber connections to fixed telephone or internet lines in many regions, health services want to take advantage. Being so widespread means mobile-based interventions are scalable, affordable, and can reach people anywhere, anytime; but is mobile phone support effective?

Does offering support via mobile phones help people quit smoking?

In answer, this recent Cochrane review summarized the results from nearly 12,000 smokers enrolled in 12 trials using mobile phones to support quitters5. The methods used to help people quit were based on standard behavioural or pharmacological support, but delivered by mobile phones. Most used simple text messages to provide information, motivation, and advice. These messages were often tailored to the persons’ stage of quitting; for example early messages would help by suggesting to set a target quit date, then later messages would advise on how to deal with cravings after the quit date passed.

Some other methods were used: one trial used mobile phones to offer telephone-delivered counselling calls, one used video-messaging, and another sent reminders to take tablets prescribed to help people quit. Most trials took place in high-income settings like the US or UK with established tobacco control programmes. The authors found:

Taken together, the authors were moderately confident that people receiving the mobile-phone based support had a 67% higher chance of not smoking at 6 months after quitting than people receiving only general health messages on their phones, or standard (not mobile-based) pharmacological and behavioural interventions.

This translates into 9.4% of quitters staying quit at 6 months, compared to 5.6%

The effect of the support decreased to a 42% higher chance of not smoking when allowing for differences in the design and setting of included studies

Focusing only on trials using a more objective marker of quitting (usually a breath test) strengthened the results

There was little difference when removing trials where controls (people in comparison groups who did not receive the mobile support) had standard smoking cessation help including nicotine replacement therapy, meaning mobile phone delivered behavioural support may be at least as effective as standard support, but these trials were relatively small and few in number, and differences in trial design and setting were not adjusted for, so this may not be a definitive finding

Should we definitely be using mobile phone support then?

Mobile phone-based support seems to help people quit smoking, but there are unanswered questions

Mobile phone based support appears to be effective, with similar strength of effect when compared to reviews of behavioural interventions delivered by standard methods; but there are still many questions unanswered by this review. Findings from the included trials, when looked at individually, were quite different. We know that the behavioural interventions grouped together in this review have different mechanisms of action, and possibly differing effectiveness; unless these are analysed separately we can’t know why or how the mobile interventions work, or which type work best. Additionally, successful quit rates vary in different groups of people, so knowing if mobile interventions are more or less effective in say, people from deprived communities with potentially lower access to NRT or prescription drugs, would also be helpful. Also, information about how often the support went wrong for technical reasons, such as through users not understanding how to use the device, or device malfunction, would help planners decide which methods may be most reliable. Finally, trials of newer support methods that use tablets or smart phones with a broader range of functions, such as specifically designed software applications (‘apps’), have not yet been reported, so were not included in the review findings.

Editor’s note: A Cochrane review is under way to explore the impact of tobacco packaging design for reducing smoking. You can find the protocol here.

David Roberts has no conflict of interest with the contents of this article.

About David Roberts

David is a qualified doctor. After several years working in hospital medicine and on a clinical trial, he is now training in public health (the science and art of improving the health of a population), and has a degree in global health from the University of Oxford. David has also recently graduated from the UK Field Epidemiology Training Programme. He has interests in evidence-based population health, communicable disease control, and helping policy-makers to use evidence when making decisions about improving the health of their population. He is authoring a review with the Cochrane Infectious Diseases Group.

Texting 2 Quit – Using mobile phones to support people quit smoking by David Roberts

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